Consider Primary Transplant Surgeon Requirement- Primary or First Assistant on Transplant Cases OPTN/UNOS Membership and Professional Standards Committee Prepared by: Chad Waller UNOS Member Quality Department Executive Summary ................................................................................................................................ 1 Is the sponsoring Committee requesting specific feedback or input about the proposal? ........... 1 What problem will this proposal solve? ............................................................................................... 2 Why should you support this proposal? .............................................................................................. 2 Which populations are impacted by this proposal? ........................................................................... 4 How does this proposal impact the OPTN Strategic Plan? ................................................................ 4 How will the OPTN implement this proposal? ..................................................................................... 5 How will members implement this proposal? ...................................................................................... 5 How will members be evaluated for compliance with this proposal? ............................................... 5 How will the sponsoring Committee evaluate whether this proposal was successful post implementation? ..................................................................................................................................... 6 Policy or Bylaws Language.................................................................................................................... 7 OPTN/UNOS Public Comment Proposal Consider Primary Transplant Surgeon Requirement- Primary or First Assistant on Transplant Cases Affected Bylaws: OPTN Bylaws Appendices E.2.A (Formal 2-year Transplant Fellowship Pathway), E.2.B (Clinical Experience Pathway), E.6.D (Primary Open Living Donor Kidney Surgeon), E.6.E (Primary Laparoscopic Living Donor Kidney Surgeon), F.3.A (Formal 2-year Transplant Fellowship Pathway), F.3.B (Clinical Experience Pathway), F.8.A (Living Donor Surgeon Requirements), G.2.A (Formal 2-year Transplant Fellowship Pathway), G.2.B (Clinical Experience Pathway), H.2.A (Cardiothoracic Surgery Residency Pathway), H.2.A (Cardiothoracic Surgery Residency Pathway), H.2.B (Twelve-month Heart Transplant Fellowship Pathway), I.2.A (Cardiothoracic Surgery Residency Pathway), I.2.B (Twelve-month Lung Transplant Fellowship Pathway), I.3.A (Twelve-month Transplant Pulmonary Fellowship Pathway) Sponsoring Committee: Membership and Professional Standards Public Comment Period: August 15, 2016 – October 15, 2016 Executive Summary Primary transplant surgeons are required to have performed a set number of transplants and procurements as the “primary surgeon or first assistant.” Primary thoracic transplant surgeons must perform a certain number of these procedures as the primary surgeon, but the Bylaws do not specify this for abdominal surgeons. Considering this, and that the responsibilities of a surgical first assistant are not consistent across institutions, the MPSC has raised concerns that surgeons could qualify as a transplant program’s primary surgeon though they may have never performed critical surgical transplant functions that would be expected of a primary transplant surgeon leading a designated program. This proposal recommends that an abdominal surgeon applying through the clinical experience pathway must have performed at least half of the required transplants and procurements as the primary or co-surgeon. Additionally, this proposal recommends that all cases accepted towards transplant training program requirements should also count towards OPTN/UNOS Bylaws requirements for all surgeons applying through training pathways. Requiring all primary transplant surgeons applying through clinical experience pathways to have performed a certain number of transplants and procurements as the primary surgeon is intended to promote patient safety and improve outcomes by assuring that each transplant program is led by individuals who have sufficient training and experience in organ transplantation. Is the sponsoring Committee requesting specific feedback or input about the proposal? • Should the recommendations in this proposal also apply to the primary intestine surgeon Bylaws requirements adopted by the OPTN/UNOS Board of Directors in June 2015? • Should the recommendations in this proposal also apply to the surgeon requirements of the pediatric component Bylaws adopted by the OPTN/UNOS Board of Directors in December 2015? Page 1 OPTN/UNOS Public Comment Proposal What problem will this proposal solve? The Bylaws require that primary transplant surgeons are to have performed a set number of transplants and procurements as the “primary surgeon or first assistant.” Primary thoracic transplant surgeons must perform a certain number of these procedures as the primary surgeon, but the Bylaws do not specify this for abdominal surgeons. As such, abdominal surgeons could qualify as a transplant program’s primary surgeon though they may have never performed critical surgical transplant functions that would be expected of a primary transplant surgeon leading a designated program. Why should you support this proposal? The changes presented in this proposal stem directly from recommendations developed by a Joint Societies Working Group (JSWG), and are representative of a collaborative effort between the American Society of Transplantation (AST), the American Society of Transplant Surgeons (ASTS), the North American Transplant Coordinators Organization (NATCO), and the MPSC. There are two primary components to the changes recommended in this proposal regarding the required case experience for primary transplant surgeons: what is required when applying through a training pathway, and what is required of abdominal surgeons applying through the clinical experience pathway. The JSWG stated it was necessary to look at this problem from those two perspectives considering billing implications of the primary surgeon/first assistant designation for residents and fellows. The JSWG recommended that the MPSC focus on training operative logs when evaluating the experience of surgeons applying through fellowship or residency pathways. This decision was guided by the rationale that if a surgeon’s involvement in a transplant or procurement is accepted by the fellowship program towards completion of their training, then the OPTN should also accept these cases towards key personnel Bylaws requirements. For abdominal surgeons applying through a clinical experience pathway, the JSWG indicated it was unreasonable that someone could qualify without some transplant and procurement experience as the primary surgeon. To rectify this, the JSWG recommended that at least 50% of the transplants and procurements reported by abdominal primary transplant surgeon applicants must have been performed as the primary surgeon. The proposed fellowship pathway changes should simplify the MPSC’s evaluation of experience reported by surgeons applying through this pathway, which will yield more efficient reviews of these applications. Similarly, these changes should clarify this process for members when trying to assess if certain staff (or potential staff) meet Bylaws requirements, and when completing the membership applications for surgeons applying through residency or training pathways. Also, the proposed changes to the abdominal primary transplant surgeon clinical experience pathways establish more consistent standards for abdominal primary transplant surgeons. How was this proposal developed? In 2013 the MPSC created a working group to address a number of issues in the Bylaws’ key personnel requirements that it had repeatedly noted as ambiguous, unenforceable, or that had prompted repeated questions from members of the MPSC. Included in the topics assigned to this working group was a review of primary transplant surgeon requirements in the Bylaws that state transplants and procurements cited on a key personnel application must have been performed as a “primary surgeon or first assistant.” While the MPSC Working Group began addressing the list of topics it had been assigned, the Joint Societies Policy Steering Committee met in May 2014 and opted for the formation of a Joint Societies Working Group (JSWG) to address the key personnel Bylaws projects being worked on by the MPSC. When presented with this topic, the JSWG believed that the primary surgeon/first assistant requirements in primary transplant surgeon Bylaws needed to be reconsidered from two perspectives- what is required when applying through a training pathway, and what is required when applying through the clinical experience pathway. Page 2 OPTN/UNOS Public Comment Proposal The JSWG first focused on these requirements as they pertain to primary transplant surgeon training pathways (e.g., OPTN Bylaws Appendix E.2.A (Formal 2-year Transplant Fellowship Pathway); OPTN Bylaws Appendix H.2A (Cardiothoracic Surgery Residency Pathway)). The JSWG stated that fellows are always noted as assisting surgeons on hospital billing records, so differentiating between primary surgeon or first assistant experience during a surgeon’s fellowship is not the best way to assess that they have the requisite training and experience that would be expected of a primary transplant surgeon. The JSWG also acknowledged that